Provider Demographics
NPI:1124544606
Name:RYAN, MOMCILO (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MOMCILO
Middle Name:
Last Name:RYAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 HARLEM AVE APT 3I
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2090
Mailing Address - Country:US
Mailing Address - Phone:630-452-9920
Mailing Address - Fax:
Practice Address - Street 1:2901 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-3637
Practice Address - Country:US
Practice Address - Phone:708-863-6833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.300557183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist